NUR 112_NUR 112 - Pediatric Asthma Case Study | UNFOLDING Reasoning

Pediatric Asthma UNFOLDING Reasoning Jared Johnson, 10 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Clinical Judgment 3. Patient Education 4. Communicati ...

Pediatric Asthma UNFOLDING Reasoning Jared Johnson, 10 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Clinical Judgment 3. Patient Education 4. Communication 5. Collaboration © 2016 Keith Rischer/www.KeithRN.com UNFOLDING Reasoning Case Study: STUDENT Pediatric Asthma History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan). In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes. Personal/Social History: He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home. What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: -10 y/o African American Boy -pts age and race can be risk factors for other complications -History of moderate persistent asthma since 6 y/o -Pt history explains his current complaints -Admitted w/ acute asthma exacerbation. -Pt is having an asthma flare up episode, admitted diagnoses effects POC -C/O increased chest tightness and SOB -Both signs of asthma -Has been 50% PEF w/ no improvement w/ MDI -Shows impaired gas exchange and ineffective treatment -Pt is breathless at rest -Shows pt severity -Course expiratory wheezing thr/out both lungs w/. -both signs of respiratory distress and an issue w/ lungs Decreased breath sounds at right base -90% O2 on RA. -sign of resp distress and impaired gas exchange -Skin color ashen w/ dark circles under eyes -signs of resp distress -Using accessory muscles to breath and has moderate -signs of ineffective breathing and lung function and resp distress Intercostal and substernal retractions -3 past hospital, 1 ICU admissions r/t asthma -pt is often hospitalized for this condition -Pt has never been intubated -pt condition has never gotten to the point of needing intubation RELEVANT Data from Social History: Clinical Significance: - - - -Pt mom and sister came with him. -pt has a good support system -lives in an older housing development in city w/. -pt has a good family at home and support system, but an older house exposes him mom Maternal Grandmother, and sister him to older toxins, dust and mold, exposure to city air too -Good student, likes to ride bike and is a goalie for -pt enjoys being active which promotes healthy lung development Soccer -No tobacco use at home -no tobacco use which could negatively affect his lung health What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: Moderate persistent 1. Fluticasone/Salmeterol Steroid/ bronchodialator Swelling in airways will decrease asthma DPI 100 mcg/50 mcg 1 inhalation bid 2. Albuterol HFA inhaler 2 Beta2 agnoists, bronchodialator Bronchial muscles will relax for air to pass through puffs every 4-6 hours as needed for symptoms 3. Montelukast 5 mg every Anti-inflammatory Treats symptoms of asthma evening at bedtime © 2016 Keith Rischer/www.KeithRN.com Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when allowed to sit upright on gurney P: 120 (regular) Quality: Tightness R: 30 (regular) Region/Radiation: Across anterior chest